this. are those any people you work with? >> i have been meetings with several of those folks. >> since march and april? >> yes. >> none of them raise any concerns to you? job is to mitigate them. none of them identified that with all of these interviews that there were these problems? take over my cell . day-to-day operational requirements to manage the contract, manage staff. , >> what you don't measure, you can't manage. so i'm concerned thatted this of people who you work with were not communicating to you document that you knew something existed because you were interviewed on it yourself. but here we have this messy rollout that didn't work, that crashed, that only six people the first day.

we're concerned about problems nd it's puzzling to me why these key people didn't talk to you about it. they gave you no hint this is existed? perhaps i just was not included in certain discussions. what you knew then have spoken ld you up more with regard to rolling out the website on october 1? luxury of a ad the time machine to go back and change things, but i can't do that. >> i understand that. it is a matter -- did you ask someone at that time for more time? >> no. >> why not? >> because my direction was -- >> from? tavner was to n deliver a system on october 1. >> so marilyn said deliver october 1. briefingsen in on the from mckenzie that said there were serious problems. them, i n two of

believe. and this was hhs headquarters on april 4. also in the and eisenhower executive office building on april 6. briefing the problems. move it for october 1. charge of man in making this work, she didn't problems hat those existed? is that what you're saying today. >> told you or didn't tell you? just curious. >> i don't think she told us in the briefing. we have status meetings all the --e about ways to mitigate >> you met with her frequently but never brought up the extent of the concerns. not the mckenzie report, no. but we talked about issues and for october 1. >> i see. no further questions. i appreciate you taking the time

with us today. a re going to take five-minute break. we recognize the next panel of here for a s been while. so thank you again. >> thank you. next "washington zornick, george washington reporter to the nation looks at the approval for obama, and the senates rule change. and political analyst michael talks about the book shaping our nation and the immigration debate. former kingsdale, the executive director of the commonwealth health insurance connector authority. compares the affordable care act's health exchanges with what massachusetts in 2006. wa journal is live at 7:00 a.m. on c-span. >> tomorrow, american history tv continues the look at the of jfk and its aftermath, with highlights

lyndon johnson's november 27 address to congress. questions for lbj iographer, flowed by presidential historian, timothy napthalie. and at 6:00, coverage of the funeral. jfk on c-span 3. now on the health insurance update. the health and technology experts. this is an hour and 45 minutes. [inaudible conversations]

>> we are going to find a seat and allow us to get started. we will try to do it >> try to find a seat and allow us to get started. we'll try to do it on time. >> good afternoon. my name is ed howard with the alliance for health reform. on behalf of senator bond and senator rockefeller, we want to welcome you to this program to take a look at the initial almost eight weeks of experience since the marketplaces or exchange is open for business on october 1. and the major pieces of implementation of the affordable care act began taking shape.

we want to recognize our partners in this enterprise. the commonwealth fund, which is almost four baby just over 100-years-old on the washington-based philanthropy devoted to the common good. you will be hearing from sarah collins of commonwealth in just a moment. this program is important because we want to go to give you as much information as we can, and to put every piece of data that you have seen into the perspective particularly from the perspective of folks who are actually dealing with this situation. there's an awful lot of interest in the number of people registered in the exchanges, the

number of folks who can't get through on the website and the number of people who are signing up for medicaid through the portals and i would like to announce that we have completed a 50 state survey this morning and we have the latest numbers for you from each of the states. i would like to announce that, but i ain't going to do that. and in fact, i think we all want to emphasize that we are at the very beginning of a process and whether you adore or a poor the affordable care act, what you need to do is listen to the insightful comments from our panelists today about what is actually going on in various parts of the country and put that together with the policy

context that goes along with this very complicated and far-reaching piece of legislation. as i said we have sarah collins at the fund both as a co- moderator and someone who knows an awful lot about this topic and we've not only asked to co- moderate told us frame the issues in a way that will enhance your ability to digest the rest of the program. thank you for being with us today. >> thank you to the alliance and the panelists and also the great audience for coming together today to talk about this timely issue on the marketplace. the hallmark of the affordable care act is the degree to be seen at the state level and this means that the local politics and the state decision-making

will influence outcomes across the country both in the states and nationally. in particular over the last couple of months in the large variation we have seen in the website functionality and the ease with which people are able to get into the marketplace and actually n. roll. in terms of the marketplace, about 16 states and the district of columbia are running their own marketplaces and it is great to have her here today to talk about the dc marketplace. idaho and new mexico use the federal website this year for enrollment. this means residents in about 36 states are using healthcare.gov to enroll in health plans. participation in the medicaid expansion is also going to have a significant impact on

enrollment. so far 26 states and distric the district of columbia are expanding the program. about 24 states are undecided or are not going to expand. the congressional budget office has estimated by 201 201,825,000 people will enroll in the plan and they are expecting about 7 million to enroll in 2014. in medicaid a project about 9 million to enroll next year and about 12 million by 2018. so the central question on everyone's mind is will consumers enroll in the plans now that they are available and who will enroll clocks of the young and the healthy enroll in the representation of the overall population? this will be critical to the well functioning market places, stabilization over time. to learn what people are experiencing during the first initial weeks of a nobleman the

commonwealth fund in october interviewed a representative sample of over 600 adults that are potentially eligible for marketplace options or medicaid, people who are either uninsured or purchasing coverage in the ad individual insurance market. we found about 60% of those adults were aware of the marketplace in october, this is up from about a third of those in a similar survey that we conducted in the summer. 17% of these adults reported visiting the marketplace in october. at ththe age and the health distribution of those that went to the marketplace generally reflected the age and the hope distribution of the eligible population to be a read about on in five for ages 19 to 29 and nearly three quarters reported to be in good health. only one in five, however, said they would enroll in a health plan. we asked people who didn't

enroll why they haven't. 48% said they didn't enroll because they were not certain they could afford a plan and about 46% said they were still trying to decide which plan they wanted. thirty-seven said technical difficulties on the website was the primary reason. a majority of survey respondents appear determined to come back to gain health insurance coverage over the next few months. about 58% who haven't gone to the marketplace works have gone but haven't enrolled in a plan said they were somewhat likely to visit by the end of the involving-to find out if they were eligible for financial assistance. young adults were as likely as older adults to say they were going to go to the marketplace by the end of the period. they found widespread support for expanding medicaid and the state. nearly three quarters said they were strongly or somewhat in

favor of making medicaid one available to residents of their state. despite the difficulties involved in the love of healthcare.gov and other marketplaces the latest figures from the 14 states running the marketplaces show that enrollment has climbed to around 200,000 people nationwide and i think that is a pretty good estimate of the variation around it but this is up from about 106,000 people that had selected a plan or enrolled in a plan by november 2 supported by hhs earlier this month. the latest figure doesn't account for the many new and little used but probably gained coverage through the federal marketplace this month and we will find out what those numbers look like in the next few weeks. many states are supporting significant numbers in the program. among the states running their own marketplaces in the medicaid

enrollment at 343,000 people have enrolled in the program. it's too early to assess the age but there is evidence that young adults are enrolling in the plans. reuters reported this week that connecticut, kentucky, washington and maryland 20% of those enrolled so far 19 to 34 and we heard yesterday in california that that was the same percentage that had enrolled in plans in that state in october. the poor performance of healthcare.gov has been a huge and largely unforeseen challenge. but these numbers do show people are determined to gain coverage despite the obstacles they are dealing with.

there is going to be a video recording of this briefing available probably monday on our website. on the website accessible to the website. for those on c-span and computer access you can go to allhealth.org to do the background that is embodied in the materials that are the folks in person attendance have at their disposal.

either by filling out the green question card or by coming to one of the microphones that you can see in the audience. and at the end of the briefing, we would appreciate you calling up a blue evaluation form and giving us some feedback that will allow us to improve these briefings for you in the future. >> let's get to the discussion we have a traffic line up for the national and state and community level perspectives that i think will help you understand what a load of the noise that you hear is really about and we are going to start with the executive director of the national association of medicaid directors. he has all of the state and territory medicaid directors and many of you may know him from his work at the governor's association working on the

health reform agenda is from the governor's perspective. how is in rome and going in the various medicaid states. as sarask sarah pointed out the enrollment in medicaid is outstripping actual enrollment in the exchange plans themselv themselves. what's happening? >> thanks a lot, ed for hosting this and to everybody here. it's exciting to see people coming about what is happening in medicaid. before i get into sort of talking about some of the medicaid and marketplace dynamics i think it's important to take a second to give a little bit of brief context on what exactly is this program throwing around numbers. we are expecting 7 million here and 9 million there.

it's the largest most important program you probably don't know anything about. we have 72 million americans walk through the doors at some point in time last year in medicaid. 72 million. the largest health insurance program in the country. we also spent $430 billion last year and what does it look like the face of medicaid is also a tennis population. pregnant women, low-income families but all of the dollars in medicaid are in seniors and with disabilities, long-term care. and the other important thing to note is that as ed pointed out as you would over or up or the aca really one half of the trillion dollars that they spend over a ten year window.

i want to go out there and put some context. what are we doing trying to -- the state experience to get ready for october 1, getting ready for january 1. and then came october 1 and we shifted back to weekly which is a lot of work for our members at the time that they are really busy and it's important and to get a sense of what is going on. all of this information, the monthly, the weekly, everything moving forward is available right now on the website. medicaiddirectors.org. sign up for the newsletter and

get this stuff pushed out. it's great. and a couple of days ago we released a sort of snapshot with the broad state perspective on housing and how things have been going for the past couple of months. really talking about the states and so this doesn't sound very sexy but it's really important. it's designing the systems that make this work. it's how medicaid interfaces in the marketplace. it's the enrollment efforts that they are undertaking and at the end of the day it is how do we do this in a way that really benefits the consumer because their experience really matters here. if they are not happy, they are not calling -- they are not calling president obama if they are not happy in the consumer experience. they are calling us. so it is incumbent upon us to figure out how to make this work as best as we can for that. >> and i think either is a point that can't be stressed.

the states come at this from very different perspectives. the eligibility in the 1980s and this is a perfect opportunity for many of them to modernize. because no one else runs the systems into the states are coming at this from a lot of different perspectives. and here is a point that is also really important. regardless of whether a state has made the decision to expand medicaid or not, then to do a state exchange or federal exchange, every single state has had to do enormous work and totally overhauling a lot of

their systems and ensuring this connectivity with the federal hub and the exchanges that is building eligibility systems, reworking your application procedures and business processes that live underneath that. again it's figuring out how do you communicate that information seamlessly with the hub, and then thinking about again, once you get people in, how do you make sure that you have to deliver the infrastructure in place to make sure they get the high-quality care that they need? and eight damn, this is a lot of work. anybody that says how hard can it become obviously they have no idea what they are talking about. this is some of the most competitive stuff that has ever been done. and just purely from the federal side, where you are talking about creating a system that has

reareal-time seamless interactin between the hhs, the department of labor, the irs, treasury, homeland security. this is not starting up amazon.com. this is a manhattan project, and again the state experience with preparing and developing and building it systems is not a real pretty one. and we hear from our states that the basic rule is the number of times that a system that you have procured comes in on time on budget the rollout is going

to be bumpy. states try to build up their own estate systems, and i think it's important to keep in mind. these things do take time. a couple things come it is a little too early to be drawing the broad conclusions and we are less than eight weeks i and if e have that data from a relatively small number of states. what we can see from the numbers is that the medicaid enrollment is higher than people thought. it's higher than the exchange enrollment and i think that there is a lot of reasons for that. the states that' that have a ste

exchange, the states that are doing the medicaid expansion there is a pretty tight diagram of the states and they are in a strong correlation with the states and efforts to do a aggressive and targeted outreach. going out and looking at the beneficiary, people who are getting other types of local benefits you know who these people are and what their income is into the euro k. getting government benefits. will you reach out to them and say we have something you might be interested in was medicaid? it isn't a surprise they come back and pretty large numbers and say yes we are interested. while those numbers be sustained, like four to one or whoever it is? what we will see is the medicaid enrollment that we have seen will go down into the exchange numbers will go up.

but in all what we are seeing is the numbers according to the states we talked to which is pretty much everybody, it is largely consistent with what their projections were at the onset. and so, what the states are doing though is it is a constant quality improvement process. and as they are building systems and as they are interfacing, they are testing and they are fixing and they are patching and sometimes they have to go back and resorts to mitigation strategies. sometimes they have to go back and do things with paper and romance. this happens. it's okay. it's in the mitigation strategy to get us through until we get fixed. but the things that we are going to be watching for or who comes in, who comes in the door. are they newly eligible or were they a group of the eligible but not enrolled, the wood works and sometimes called welcome mats.

that makes a huge difference in terms of the federal government pays for an hundred% of one of the group, the expansion group. they don't pay anything additional to the other that matters. the other is what is the case? are they coming in young and healthy or are they older and a sick and have substance abuse and mental health disorders, this matters. i'm out of time so i'm going to run through the last slide or two. and i think the success stories in a lot of states see is if you can treat the rollout of the exchange like a soft opening of a restaurant come and build some functionality in early and then build upon that. that's where we have seen the most success. it isn't always possible but that is certainly something that we have taken away. finally, you know october 1 is important, january is going to be even more important it has been covered to actually start.

and we have to make sure the system is ready for them and then finally closing it is the easy part. once you get them in the door that is the easy part. with 72 billion plus people, 400 billion plus dollars a year, all of the sick and the fraley and the disabled and the chronic conditions, we have got to do more than just keep them covered, we have got to cover and then at th to the cost curv. david blumenthal at commonwealth has done a famous job explaining this. this is what the states are doing that i think it's is reay exciting news. i'm going to do another session on this. reforming the delivery system and reforming the way that we pay for care in this country. we have to treat health care just like a bunch of economic and the words paying for value

that is with medicaid is focused on these days i will stop there and look for questions at the end. thank you. >> that is a great start this discussion and now we are going to turn over to daniel skyler who is the director of exchange technology and a former director of the technology for utah health insurance exchange which has been in business as long as anybody. his colleagues have been helping a number of states prepare for the implementation, especially the exchanges and we have asked him to talk about -- we have heard that there are a few challenges in the area of technology, and have asked him to talk a little bit about the challenges and the other challenges that the states are

facing in your experience. thank you for being with us. >> i appreciate being here. >> i am going to give you an overview of health reform in utah and talk a little bit about healthcare.gov and with the state-based marketplaces are doing and then just sort of try to get some guidanc give some ge remaining uncertainties. but, matt said it's the best and i think that it's fair to point out that public changes are the most complex, one of the most complex it projects ever initiated by states and the federal government. and the reason for that is all of the plaintiff integration pon that exchanges need to make. they need to connect with medicaid. they need to connect with the federal data service hub and carriers across the country. with that i will go ahead and give you a little bit of background on what we did in utah.

so in 2007 and 2008, utah passed to the any willing language to build a health exchange, which is now known as the avenue age. the impetus was to provide a tool that employers could use to help mitigate the rising cost of health care in utah. one of the ways they did that was by establishing the contribution marketplace which would allow the employers to go by their employees with a set dollar amount every month that they could use to go into the exchange and purchase any health plan that was available in the exchange. it provided critics of the become a more options and more administrative cost to the employer and 40 employee to provide more choice, transparency and portability so if they move one job to another they could take their plan with them. it's been very successful. many of you know that utah has default it to the facilitated marketplace for the exchange but

they have been given a waiver to run the avenue as the shop exchange in utah. with healthcare.gov, what happened? why did we see such a miserable launch on october 1? there are two things that speak to the causation of the failure if you will. one of them was the lack of time to build and test. and one of the reasons there was a lack of time is the hhs, cms delay the necessary regulations and guidance to provide the business rules and processes if you will for how in exchange should function or how the subsidies should function or healthy integration should work. all of the nuances with regards to how it should function and it was sort of like trying to build a plane while flying in the air were a race car while it is going around the track. we were trying to develop these

rules and regulations and guidance while planning the development and the build of the exchange rate of the administration delayed internal progress and there was no end to end testing rate they tested the components individually but because of the time to the test, that led to the issues that we saw october 1. additionally, as the cms and hhs admitted they decided to take on the role and responsibility of managing the project internally. the administration was advised that they should live or -- letter then to one of the largest it projects ever initiated by the federal government and they chose to bring that in and do that on their own. we see what happened on october 1 with a lack of knowledge and to guide a project

of the size. there was also a lack of communication between the subcontractors and the general contractors. again this is a part of the overall project management. the subcontractors would express concern about a certain component or certain issue and that would never filter up to those in charge that could take the necessary adjustments to the project plan or the necessary adjustments to resolve those issues. so, if we look at the state and what happened with retrospect with healthcare.gov, what do the states do differently, and we are seeing more success with the state-based marketplaces. so, i mentioned in my sort of touched on the state leveraging existing technologies. they went out and hired the best practices. they hired a system integrators and project managers to oversee

their implementation. they were proactive and innovative instead of waiting for the guidance to come out, they started their guidance project planning early on and started to build and design their exchange without the necessary guidance from hhs. that did require them to make changes as the guidance came out. but because they started early, they were able to achieve a level of success that we saw in october 1. the scope was necessary. so they look looked up at the ce fundamentals of the exchange were to start on boarding people. and sort of if you will remove all of the towels and whistles and just focused on developing the core fundamentals of an exchange and they set expectations low. they were proactive in the media and with consumers letting them know that this was going to be a bumpy start on october 1. we aren't going to have all of the bells and whistles. we are going to deploy the core

functions that will allow people to enroll and begin the eligibility process. all in all, they took a completely different design philosophy versus the federal government when it came to building the state-based marketplaces and in retrospect if it might have been organized by date might have been appropriate for the administration to have collaborated with the states in some respect doping in exchange we might have seen a different outcome on october 1 with healthcare.gov. but again with healthcare.gov, they now have some project management in place through the heavy contractor overseeing the repairs to the platform. we are seeing progress on a day-to-day basis and improvements to the platform. not sure where we will be on november 30. the administration said that on november 30 event 80% of individuals will be able to take the enrollment process and 20%

probably will not because the core design issues that still need to be addressed as well as the complexities of the specific eligibility scenarios that matt spoke about. we will have individuals that will have a sporadic residency or citizenship or have never filed an income tax return and that will advocate the complexity of determining eligibility for the subsidy before the system can accurately enroll people on a consistent basis but we will just have to see where the platform is on october 1. so, just want to end with federal health reform uncertainties. enrollment plan b. we heard the administration emphasized the carriers int and the web-based entities. there's been a lot of confusion in the media. exactly how that works with

respect to the carriers can and cannot do. but i think the administration is making a proactive decision to encourage consumers to use direct enrollment into the concern is that the character moment on the web-based entities is not fully completed you're still working on the technologies to ensure that path works. premiums and cancellation fixes the administration announced as to how that is going to work in what will happen to the premiums. will this destabilize the risk pool going forward? and there is a lot of uncertainty what that will do to the premiums and 2014. state-based exchanges. what states thawith states thatg the marketplace were healthcare.gov will transition to the state-based marketplace over the next two years. i think in some respects the rollout of healthcare.gov will be a catalyst for some states

including the partnership to quickly transition and in other states that have been adamantly opposed to the affordable care act this may reenter and then in the position to not build the state-based exchange but we anticipate that many of them will transition over the next two years to the state-based marketplace and some, not all, of the federally facilitated barkett place or states that are utilizing the federally facilitated marketplace will transition. last but not least, funding. the federal deficit. what will the funding look like for the ongoing development of exchanges? states have until december 2014 to apply for a draft to build an exchange. the question is will that funding still be there at the end of next year? thank you.

>> that's great. thank you. even if you did end with questions instead of answers. we will get to you later with the answer part. >> ms. kaufman is mac stand as the winner of the award for the shortest distance traveled by a local official to get to one of our briefings. that is to say she is the director of the dc health benefit exchange authority. in previous lives she has been among other things the superintendent of insurance in maine and the insurance commissioner. today with that, we are here to discuss the experience and dc at the marketplace which is one of a handful being run by the local jurisdictions. thank you so much for taking a cab into coming over. >> you had me there. i thought you were going to say

we had the shortest amount of time until october 1. the city didn't sign its contract with the systems integrator until january of this year. so we were the last to the picnic and one of the first out of the gate i'm proud to say. so thank you so much for having me here and i just want to say how important your -- this particular session is and how critical the research that the doctor has done on the first 86. it certainly is informative for everyone but especially people on the ground who can then take the research and utilize it to be more strategic in our own outreach and enrollment strategy. thank you very much for your commitment to helping not only policymakers but folks who are on the ground implementing the reform. in the district is really did it take a village and i just want to acknowledge some of my staff

members who are here. my deputy and alison nelson. when i came on board in january as the executive director of the health benefit exchange authority, i was the first employees alike off to build my team and i just stole the best people i could find from everywhere the private sector talks people out of retirement from the federal government from the hill and from everywhere. i was very fortunate to have a great team help us get to the finish line in helping us succeed. we had to prioritize. we have the core functionality. we took the bells and whistles

off the table and focus on the core functionality that we wanted to make sure on octobe october 1. do everything start to finish and we were able to do that october 1. they were able to shop, they were able to select the plans. they were able to come and set up their accounts as well so this is just our landing stage i want to make sure that you are aware. we are not the federal site and we are fully functional. we are by the start in fact we have all of the major insurers

offering coverage to the individuals and small businesses on the individual site we have aenta, blue coffee and blue shield and kaiser permanente and then for three plus united healthcare. we are very pleased with the fact that all of the carriers are in fact participating. for both individual and small-business consumers at all levels of coverage. from bronze to platinum. when a small business comes to us to offer for all that are in the particular level is a small business offers the gold level coverage that means workers can

choose. so everyone in the gold level and there are 112 different products. so any of the insurers they can choose from any of the hmos or point of service and the products you can get no deductible plan or you can get a high deductible plan and everything in between. i wanted to include a slight on the price since that's been in the news quite a lot. on the individual site you can get a bronze level policy for

$124 a month. if you are 55 and you live in the district, you can get a bronze level policy for $295 there are very competitive prices. i want to note that when we posted our prices and adopted legislation that requires full transparency in the pricing we solve a real price competition and the proposed rates for fidelity and we made those rates public. one insurance company came back and lowered the rates twice. the proposed rate and another company came back in and lowered their great ones and a third insurer came back in and low birth rate at an additional product. so, in the district we saw price competition work through price transparency. and of course competition greatly benefits individual consumers as well as

small-business consumers. we have a lot of activity by the district, lots of shopping any accounts being opened up and lost people picking their plan and requesting the invoice to pay. i am not encouraging anyone to be early because they have until december 15 to pay. so i want to make sure that anyone who lives here in the district watching this knows that they have until december 15 to pay. nonetheless, some have paid and doctor collins asked me to share some early statistics with you, and this is -- i had my staff look at the first 120 people who fully enrolled themselves paid getting selected at the plan and paid. so the largest category of enrollment in the first 120.

the category of the first 120 enrollment. i think that most of those to those that already paid only fully enrolled the levels actually surprise me. i thought that it would be more evenly split in terms of selections. the interesting fact that i would like to share with you is that we have several enrollment age 65 and over. ..

there was a senate which had each state setting up their own. included one of us, me in state government, lobbied

state-based opportunities. we argued that states can do it it bert, weave done should do it. and so part of the issue has that so many states who lobbied heavily to have the to -- the opportunity to set up their own exchanges decided not to do that. and so i think we have to keep set in mind when we expectations about achievements opportunity for success when the federal government having to set up a marketplace, a very complicated on-line in so many jurisdictions. thank you. >> all right. thank you very much, mila. y the way, your last slide reminded me that if you are and ing about this topic this event, there is a hashtag

title slide, hashtag acamarketplace. right?do that all >> you sounded very twitter savvy. >> right.. >> right. our final speaker is katy caldwell. she's the executive director of legacy community health services. they are a federally qualified health center in houston that's been working or actively to help his patients with both aca and medicaid enrollment and she's here to share some of their experiences, they being both their patients and legacy itself, with us. we are very happy to have that happen. katy. >> thanthank you, ed and sara. so i'm going to start with just a brief introduction of who legacy is, how we are navigating the system and how our patients are navigating the system, what the interest level that we've

seen, what are successes and opportunities have been, and what are our next steps. legacy is a federally qualified health center. we are in southeast texas in both harris county and jefferson county, which is houston and beaumont. we have 11 clinics, and clinical locations and seven school-based clinics. our clinics are located in historically a neighborhood, hispanic neighborhoods, an african-american neighborhoods. we are a certified application counselor organization. we have 28 certified application counselors, and we see, this you will see approximately 60,000 individual patients through 200,000 visits. so also i would be remiss if i didn't say texas as i'm sure all of you in this room know, this is not medicaid expansion state, so, therefore, only children,

the elderly and disabled are still eligible for medicaid. we are also a, on the federal run exchange we did not object to a state exchange. our marketplace and how people are accessing it, they are coming into our clinic, making appointment or walking in. they meet first with a certified application counselor who starts the process by getting them to walk through the consent. this causes a lot of anxiety for some people, and because they've heard a lot of bad publicity. declared about identity theft. there's also been several groups in houston that have been fraudulent groups out collecting information from people, and basically stealing their identity. there's been a lot of publicity around it. we have to get over some of that anxiety. then we have to determine the client's knowledge. and this has been interesting. we need a people didn't really

understand insurance but we've had a lot of education around just even the terminology and insurance. the majority of people coming in have never had insurance. a lot of them have low literacy, to begin with, and low health literacy. this group, especially the people have really not, are really uneducated on insurance, a bit information overload at this point. many times they leave, they take information and make another appointment to come back. if you have other information with them, we go through their household information, what subsidies they might be eligible for, the different ways you can apply. we get from all their documentation in the design which means applying is the best for them. is the online application or the paper application. one thing that has surprised all of us has been also about a third of the people who have come in have never used a computer.

and another third have a computer but have no internet access. and then the of the third, they have a computer and have internet access them so some of our folks are taking time now to help you get e-mail addresses and also connected them with resources in our community where the low-cost internet access and low-cost computers. and then we assist them in getting on and getting an application in the marketplace. and then work with them to determine what's the best plan for them. the other part, about half now we are doing and paper application, and this is largely because of the language issues. we are a very diverse community, and online is only available in two languages and we try to do everything in the languages of origin of our clients because they understand things better. there's 11 languages on paper but only to online. and it takes longer to do it on paper because of the length of

time of submission. the next part if they haven't had information overload again, which most have by this time, or if they have to submit my paper we ask them to come back with their eligibility. so then it's determining which plan is the best and making the application, and this again becomes very complicated especially for any of our clients have chronic illnesses such as hiv, diabetes, congestive heart failure, asthma. because they had to look not only at often times the lowest cost plan on the premium is not the best plan for them. and it's not easy on the federal exchange to go through and compare medications, formularies, to compare what doctors, what hospitals are on different plans. so you have to take all those things into account, and explain what all those things mean to people. eventually though they get through the application process and will choose a plan.

so who are we seeing and he was asking? just to our location we've had about 3000 inquiries sense, that we've been tracking since october 1. we've seen about 1300 individual people, most of them, the average number of visits has been three visits with our folks. we completed 89 applications and have 18 people go all the way through to enrollment. majority of the people coming in our our existing patients. so that a high level of trust with us and they're the ones that are really getting through the process much quicker than the ones who are coming to us from various outreach events, from finding us on the internet. we're also seeing a very strong mix of age and race across every age that we've been seeing. we have seen quite a few people coming in who are 65 and over. just wondering what this is all about. we end up helping them a lot of times choosing the appropriate medicare part b plan for them.

so we're helping on that site also. -- part d. we were surprised how many young families were coming in. host of young families coming in, the children are already on medicaid and the coming in for care for themselves or other family members. so our successes and challenges, so what's working? the system is improving. the awareness level is increasing and good publicity, bad publicity made people aware of this is out there, the marketplace is open. so it's about more people in. most people are surprised when they come at how affordable it is. i think there's a preconceived notion by especially people who have sought some of the high-risk pools are people with chronic illness in the past have been unable to really afford it. but as with the d.c. exchange, there are trees prices and people are really surprised that

it is affordable. we are doing a lot of advice in a committee. with a couple of organizations that do free and low-cost tax services, filing services for people of low income. so we're doing a lot of that. we are collaborating a lot with other groups and with other nonprofit organizations. so what are the barriers or opportunities? trust. trust is a huge issue. again, the majority people who come in do have a lot of skepticism in the system. a lot because of the publicity that there's been. online access in letters he has also been an issue, and learning insurance terms, understand what a co-pay is, what coinsurance is, and just what a premium is. homeland security is very large in our community, and there's

lots of people are fearful that while they may be a citizen and ineligible, their people in the household or families who are not citizens and they are hearing from the irs, so it is very real. also hear from other law enforcement. the information will be available to other law enforcement agencies. setting up e-mail accounts but lots of people don't have e-mail accounts. that was a big surprise for all of our staff, and also the other issue, inability to compare easily a different plans on healthcare.gov system. what are our next steps? were doing a series of town hall meetings to encourage both our patients and people in our neighborhoods to get educated and doing large education sessions. we are setting up in our lobbies of our computers online access for our patients so that they can come in and do some

exploration on their own or get comfortable with the computer. we're doing actually some more computer literacy classes, and assistance with that. we are continuing to do all of our outreach and engage potential enrollees. and then we are starting in january going to be doing a lot of health literacy for our patients after of the members in the community. because once again just because you have insurance doesn't mean you know how to use it. and what our goal is, at our health center is to make sure that so they get insurance, that doesn't mean to go to the emergency room when they get sick like they've been doing and they are in the habit of doing. but they learn if they have a health care home and how to use the insurance at that health care home. thank you. >> thank you. all right. well, we are into the part of the program where we give you a chance to check out the

questions that might have been raised by the presentations you just heard. i would also encourage the panelists if they have heard something they disagree with our want clarification about from one of their colleagues on the panel, they should speak up at any point that they would like to. and, of course, sara is in a position to ask very informed questions. if you did go to the microphone i would ask that you identify yourself and try to keep your question as brief as you can so that we can get to as many of the questions as we can. and you had the honor of the first question. >> thank you. bernadette with congressional resource services. i a couple of researcher question. the first one to my love. your initial -- mila. gravitate to plan is a question about what you to be the to? are these folks uninsured with

pent-up demand, are the kind of tied with the over 65 but maybe just are looking for more generous coverage? that's my question to you. and into the broader group, kind of looking forward beyond broad david and premiums, is there any plan to put additional information out there such as enrollment by demographic categories as well as additional plan features like cost-sharing requirements? >> thank you. so i wish i knew, is the short answer. and i should caveat all the initial numbers i gave you by saying, i don't think it's a prediction of anything. it's just looking at the first 120 period. i think it's interesting that pretty much every age category is represented. including the younger population, of course, enrollment you want to make sure

that you are targeting everyone and you have a healthy risk mix. and i do not know anything about the short status of enrollees. we actually, unfortunate, did not bill that data element into our application so we are not collecting it. we do plan to do a survey in 2014 of all of the enrollees to ask them whether they were previously insured and what kind of coverage they had. and we do have plans to closely examine our data, probably early to mid-next year, once all of the dust settles and we have good data to look at. and we will be making all of our information, the demographics, enrollment statistics all public once we have good data to share. >> have others on the panel

experienced the same sort of platinum coated enrollment phenomenon that milo was describing? >> many of ours have been silver vessel we are seeing. but we don't have 18. [laughter] >> not a representative sample by any means. >> also on the data availability, i think that's a really excellent question and really i don't is looking at this carefully wants to know who is enrolling. the caldwell fund will review our survey that we did in october in december just to get another snapshot of what's happening in the marketplace. hopefully we'll have a little more sample so we can have a better idea at least in a very broad way of who was coming in, and then go in at the end of the open enrollment period again with a little bit larger sample. in terms of a national data that will be available, national health interview survey data i

think will be the first national look at, at least at a broad individual market level perspective available starting in september. we will know what the first quarter coverage look-alike in this year. so i think the state reports, my list report just now is so important, so interesting and in california, other states that are recording, demographics this division are going to be really important to understanding what's happening. >> all right. go right ahead. >> i'm a legal intern at hhs. i've a question that's mostly directed for katy caldwell spin could you step on little closer to the microphone and? >> canyon me now? wow. i'm illegal internet hhs. my question is directed to katy

caldwell. how is your health center responding when you encounter people who fall below 133% of the poverty level? and also, do you help people realize if they're eligible for subsidies? >> on the subsidy question, yes, we do help people determine whether subsidies are. that's the easy one. the hard-won is telling people they're too poor to get a subsidy. and it is difficult and we haven't people coming in now looking at that, that i fall into that category. if we had expanded medicaid they would be eligible. so we're talking to them about just when we do, whic which is e your options if you come here to care, we do everything on a sliding scale. we will help you in any way that we can, but it's still using our

grant funds and other funding that we have to help care for them. and what our goal was then is to educate them again like we do it all of our patient, try to keep people out of the emergency room and keep it in routine care. >> and just to put a data point on that, too, the size of that coverage gap population, kaisers number is right about 1 million people in texas. so that's a considerable number of people your. >> hi. my question is for mila. are you concerned that there's over 100 plans to choose from, people will be overwhelmed by the choice, or they would just choose based on price? it was a problem for part d. it's still a problem for part d. people are reluctant to go back in and make another choice. and i think kaiser has shown that they don't make the best

choices? >> thank you for the opportune to clarify. so, on the individual side we have 34 products. 31 our meta- levels, and three are catastrophic. so on individual side there are fewer options, fewer choices. on the smoker decide, on the shop side, 267 different products. we know from experience that small businesses themselves are like a choices. if a $15 co-pay is right for one small business, another small business wants a $20 co-pay. so we know that from the massachusetts connector experience in small group market and we know that based on the commercial side of the market. and i have a private board that made many of these decisions with a lot of input from policy

stakeholder workgroups. so we decided early on that we wanted, that we didn't want to limit products. we wanted carriers to be as innovative as they wanted to be. the one early decision that we made, which was unanimously recommended by all stakeholders including consumer groups, providers and carriers was that we would not allow benefits substitutions to the central health benefits package. and so that products could have additional benefits like acupuncture as an example, if not one of the core benefits. so the variation in product is really additional benefits on top of the essential health benefits benchmarked and the variation in your out of pocket liability. so the co-pay, coinsurance, et cetera. >> thank you. spent thank you.

i also work in coalition with many asian-american organizations. so my question has to do with the language barrier. have you seen the problem cents we have not only on paper? you said 11 languages on paper and only two languages online for the application. so does that pose any problems? in virginia, we have a high percentage of asian americans in virginia and its rising but virginia still not choosing the american expansion decks i don't know if you have any number from healthcare.gov, from the federal site. how many asian americans coming in and giving problems about it is anything that you think the committee should step up and work with you? because as i understand we'll have two mitigating in virginia. and with tremendous amount of

asian americans, small businesses and many of us are not inhabit at that insurance. i can talk from texas. it is a problem we have the largest been in thi in these coe in the country in houston, and we are pushing to get the third language to vietnamese for us. and, but it is a problem and we're just glad that there are at least 11 languages and we run across people that it is not that we don't have the appropriate language. in those documents. it is an issue. because it is much easier for people to understand in the language of origin and so we are working with everyone to try to get better access. but yes, the answer is yes, it is a big barrier. >> so in the district our

biggest immigrant population is spanish-speaking, and the next largest is ethiopian community. and then we have also a nation population. for asian and pacific islanders we a partner with our mayors office, and our partners are essentially doing on the groundwork. we found with working with different culturally different groups, that having a working online portal is not relevant, and that many people, many immigrant communities, small business owners and individuals really like the one in one interaction with a trusted voice. so we actually have focused a lot of resources into the on the ground people in the community

who can work one on one with a small businesses and individuals, with all of our the first populations. >> what kind of relationship do you have with the insurance brokers in the district? >> so, from my perspective, excellent. we actually have the brokers involved very early and we build a broker portal. so there's a consumer portal and there's a separate broker portal that's designed to help it, help make it easier for brokers to place business to shop at. we have very good feedback from brokers and, in fact, we're doing some enhancements to our portal based on some feedback from not only consumers but brokers using the portal. the other point i just want to add, we also partnered in a formal way with the national association of health

underwriters and they did all of our broker training. which also helped a lot. we also have partnership with all of the, most of the business associations like the d.c. chamber of commerce, the restaurant association and the hispanic chamber in d.c. and that is held a whole lot in terms of not only educating people about the affordable care act and all of the opportunities, and also being trusted messengers, and now those business partnerships, they are helping us with enrollment as well. >> him david helms. more to this discussion, i led the robert wood johnson's health care for the uninsured program when we tested voluntary subsidized products for the working uninsured, and i am interested, mila, and those who have had a chance to look at the

plans, the "washington post" of course discovered that maybe some of these plans will have to have narrower networks that may exist in the rest of the market. and i would report that there are no easy ways to make health insurance affordable. and we tested a lot of these from purchasing cooperatives to subsidies, the narrower networks. and from those early projects reported in health affairs in mending the flaws in the small group market, note that the uninsured were not unwilling to use narrower networks. they wanted the range of care from hospitals and ambulatory and so forth, but i just wondered if you were hearing any or seeing any evidence that looks like this will be the next issue people want, not everybody's going to get him the same choice of health providers maybe they had before. >> i can say that in the

district, the products that are being offered are very much, in terms of the provider networks are very much the same as currently in the commercial space. and so about half of the products offer nationwide networks. and the other half very robust local and regional provider networks. i don't think there's a single product that was filed to be filtered that has what we would consider a narrow network. >> i might add that i would say that from a macro perspective, narrow network company, it connotes different things. it doesn't necessarily mean bad quality. there's a lot of providers out there. i don't know that we want to be with. and i think it is an inexorable move in the insurance industry in this country towards narrower

networks. selective contracts. obviously, ideally you want to do that so you've got a high quality low cost providers within that. but let's not try to pretend that's necessarily a bad thing. >> and i would refer you to the briefing we did last week on reference pricing for a number of private sector entities were moving in that direction in a very large-scale. >> i believe you were next. >> hi. hello? does this work? on monica from gao's office of general counsel, and one of my practices is and how flaky an aa question for dan and mila about the bells and whistles you refer to -- >> get a bit closer to the microphone. >> sorry about that. those of you refer to bells and whistles in the cms federal system and you pointed out that one of the things that led to the successful design and implementation of the csm or the other state systems we scope and requirements and to cut out the

bells and whistles. in comparing that to the federal system that has to interact with the hub and the carriers and make that, make the decisions for the applicant come what are some things you can scope out? >> like what are the bells and whistles? >> so just for the record i did not say we scoped out anything. we actually write should be. so we still intend to do everything that we plan. we just couldn't do it before october 1. so it's just been right shifted to 2014 and perhaps a few years but it's things like the provider network. ideally we would have a button, a consumer could click on and have access to the carriers network right there. we couldn't build in the provider network feature into the portal, and so what happens now is a consumer has to click several times. and actually from our site,

click into the carriers aside and go straight into the provider network that they carrier maintains in their website. so that's an example of a bell and whistle that we just could not do. for october 1 launch. we plan to do and we will do. it's just going to be sometime in 2014. >> my name is dan brown. i'm with the american occupational association. the lowest cost option is not always the best option for consumers. katy mentioned it's difficult to access information about provider networks and drug formularies. we've also found that is difficult to access information about coverage services, unlike in d.c., and most a substitution of benefits is allowed even if the consumer is aware of this

benchmark plan and those was covered by that plan. there could be variation in the marketplace. i'm wondering with all the i.t. problems and enrollment challenges if d.c. or other state run exchange is are actually looking at the consumer experience making sure that all the information that ideally would be available for consumers to make informed choices is available? and a related issue that is accurate, we found some information that's available on the marketplace interface that is not the same as the summaries of benefits and coverage for the plan. so i'm wondering if any state run marketplaces are looking at the availability of that information and the accuracy of that information? thank you. >> yes, yes, yes and yes.

so we found early on that it was very difficult to find the formularies, and so we worked with the carriers to make that more prominent and easier to find. but again, that formula is not going to be in our portal until next year so consumers still have to get a few clicks to get to the formulary. the consumer experience, so let me just say, the most important part of all of this is the consumer expected because if the consumer has a bad experience, then it's hard to convince the consumer to sign up, get coverage. so we are very interested in consumer feedback. any feedback we get, whether it's constructively phrase or not we take seriously. and we have a long list of improvements and add-ons we plan

to make to improve the consumer expense. we do updates to our system on a regular basis to add in enhanced features to help with the consumer experience. in terms of the contradictions and information with us benefits and coverage and what the plans actually cover, just like we build a portal for brokers, early on we built a portal for carriers. and so this summer carriers have to load all the rates in the plans and we did significant back and forth testing with the carriers so the carriers would come in to their portal to check everything out to make sure that the summit of benefits in coverage actually matches the plan that was approved for sale and there were no discrepancies. and that's how we are able to address some of the discrepancies that the plans and

identified early on. so hopefully a consumer shopping in d.c. does not find any discrepancy and if they do i want that call personally so we can address that. but i just want to invite think the consumer experience in improving the user experience is critical to me. >> office of personnel management. the federal employees health benefit program. i have two questions actually. first one is for mr. simon but i hope i pronounced that correctly. on the medicaid expansion, with large font of soldiers coming home, how these offerings for that large population transitioning even though their state may or may not be offering it because the job may or may not be there. income is cooler. how are we setting buffers? and the other question is for the state.

excess of health care now we have that. what are states proposing to deal on the clinical provider side so that we can provide services for those people? >> that's a great question. on returning soldiers, returning veterans. i confess, i'm not sure. this is not traditionally a job that medicaid takes on to try to look at. i think the court of the issue you're getting at is employment opportunities for returning veterans and i think it's a really, really important issue. i know a lot of states pay a lot of attention on the. that's not something that we focus on. so i can address that. but to the extent that there are issues there that we will take a look at that and we can get back to you. >> matt, you have one of aspect of the gentleman second question

about the adequacy of the provider networks being one of the other question cards that we have up here. someone was wondering whether there is any state that has decided to hang on to the primary care increments in medicaid that was included for the limited time at federal expense in the aca. >> so i guess the question there is, because when the things the aca did was that the increased medicaid payment rates to primary care doctors to the medicare level. which is great. but it did so for two years and then some said it. and, in fact, it was intentional -- it was intended to improve access although the first year that went into effect which i to 2013 for the expansion started and it is at the end of 2014. which i think is a terribly

cynical wit about going federal polls. the framers of the law assumed a future congress would come in and extend it and would have and medicaid doc fix just like we had so much success with the medicare doc fix for ever now. i think it's way too premature to say what are we going to do when that goes away because i think this is very much in congress is core to figure out, do they want that to just go away and in what will that get access? i think that's a question for congress and not for us. we not going to try to answer that at this point. >> i have a question for matt and a question for mila if i can. i want to ask met come in your snapshot you said you think medicaid data may be taking a want to get a better sense of that. are using different people enroll now and you saw previously? given that the enrollment data

has not been, didn't come it's been delayed because of account transfer problems, are you concerned about how solid hhs data might be? you expressed some concerns that some people who enroll or people who applied were i could already enrolled in medicaid. so how solid is the hhs data, and for mila, i'm wondering, something people here might be carries about is, do you envision any way at all people who have been assigned to go to help link to be able to go back if they want? >> so, to the first question, in terms of the data and you're right, the inability to actually do account transfers is not yet fully functional. it will come. not sure win. i don't know that's a catastrophe. i don't know that's a crisis. the issue i think you're getting

at a ransom the data which is also the batch files that are common across, it's really more of a system hhs of here's who we think will be coming to you. and here's some information about this so that states can kind of better prepare some of the workload, do we need to staff up a call center? you know, and yet, so we've seen some challenges there. you know, there's a lot of challenges with everybody's data at the onset, so i'm not care but concerned about any of that. it will get cleaned up. it's not going to be huge problem i don't think. >> yeah, i would just refer you to a pm. as you know, the affordable care act has a provision that says that certain designated staff and members can get or have to get their coverage through the exchanges.

and the final rule that opm issued as a source for qualified coverage that is eligible for the employer contribution. so i welcome all congressional staff and all members and look forward to serving each and everyone. >> yes, go right ahead. >> hello. i'm with the national association of social workers. my first question is both on a micro and macro level for katy and matt. are either of the agency level or at the association level collecting data about the turn away rate in the not expansion state? katy, you mentioned there about 3000 inquiries after clinic in the last two months. if there's any data as to how many of those were people below the poverty line, who could not get coverage because you're in a not expansion state. >> we are collecting that. i don't know the number of the

top of my head but we are clucking and we are seeing quite a few. and we know that we're going to be seeing a lot more. we are an hiv service provider and we have about 4000 hiv patients, and we know just by our data that about 1500 of those patients will not qualify. would qualify for medicaid expansion but not the other. but we are tracking it. the short answer is yes, we are tracking it. spent the at -- and the short answer is no. we are not talking. we represent the medicaid directors. we've got a third of our staff here today. you know, we try to prioritize, providing information to the members to help them better implement, so the snapshots we've been doing is really to help level set, to help states figure out are you struck him with this issue or that issue?

are you the on one or is anyone struggling with that? so we don't have the capacity to dig down and really, really be a data warehouse for everything like that, unfortunately. >> thank you. >> someone else have a question related to the. wanted to know if states that were using alternatives to the traditional or the medicaid expansion under the law, whether the states might see differences is enrollment. different approach. >> i don't know that we've seen much in terms of different enroll a. at this point we're really only talking about arkansas at this point. when the aca had the medicaid expansion and then the roberts supreme court declared it unconstitutional, it turned to medicaid expansion into a state option. as your slides appointed a, but have the state said yes, about half said no. in large part because largely guilty choice they had was yes

or no. then we had arkansas come along, very, very interesting singer we have a democratic governor and the very conservative republican legislature and governor bp went to secretary sebelius and said, i need to do the expansion. i can't get it through if it's just medicaid. let's figure out a third way. and together they worked out a plan to essentially expand medicaid but to take the vast majority of those individuals essentially and roll them by the exchanges, via the marketplace. through premiums of technique called premium support. at this point arkansas is really the only state that's been approved to do that. and i think what they are going to see is, you know, you're going to see by definition the figure, frailer, the more disabled individuals as part of the expansion will be in

medicaid. the younger, healthier, and better health risks for the pool will end up in the exchange, and quite by contention according to their calculation, their proposal, that in and of itself is going to sustain and save the exchange markets by having that bolus if you of younger, healthier lives in that pool. i think you're going to see a lot of folks in there. >> i guess this is actually a sort of same question and i was going to address to you. i just wanted to know, if you be seeing more states who have opted out of the medicare expansion who will be using that model. i think wisconsin is using that same model. i think i heard that it's going to take off this enrolled people off of medicare and put them on exchanges and then to make way for new enrollees to i guess i just wanted to your whether or not there are some downside our

upside to using that kind of model. and you think other states are going to do the same? >> so, in terms of medicaid, i would say the wisconsin issues different. wisconsin, it's funny, the wisconsin folks say why do we keep getting labeled as a non-expansion state? we expanded a decade ago. they already cover all of these people are and so it's, i think the wisconsin situation is very, very different. but i think it's a very, very silly question to talk about, what does arkansas mean for -- salient question, for the other states that are currently either leaning know or are at no. and i think, i know for sure that the vast majority of states who are currently in the no category are i would call them

in, they are in the know, but looking for a way to get to yes. and what it is they look at the options that they have. in the options they have are expand the program as is or nothing. they keep coming back and saying, there's got to be something more on this. it's got to be another option. arkansas has got one. is there another option for us? and i think would at the end of the day it's all about whether or not those individual states because of you all ask for slightly different things, pennsylvania and michigan and iowa, they are all asking for slightly different things. it's really going to come down to is the administration going to be willing to work with them to come up with a fourth option, if this option, a way to get there? i think the arkansas model, was the conservative flavor of the

private sector approach, and as a way strengthen the exchange market the potential to be a big win-win for everybody if the cards so of on. >> this also raises the question that dan brought up earlier about the states on the exchanges also on the marketplaces who are doing plan management, there are about 14 states that are doing a little bit more than just, than some of the other states. whether we will see a shift in that responsibility, taking on more of, states taking on actually the market place operations. maybe talk about that. >> allowing states to transition from a partnership model or a fully federally-facilitated marketplace over the next two years. states were anticipating filing a blueprint on november 18 that, the states that were interested in doing that transition and we'll have to see how many states actually filed a transition blueprint.

but they have until the end of 2014 to make that decision. so again, we think there's a lot of into this for many if not all the partnership states to transition over the next two years, and some of the ethics in states that will just have to keep an eye on the state and see which ones do. -- ffm states. spent as we going to last 10 minutes or so, i would like to ask you to pull out the blue evaluation forms and fill them out as we get to these last few questions. i would like to ask you to ask your question. >> hi. i've got to question. the first one is just about the enrollment data that's been released in terms of young people, so maybe sara and mila you guys can answer this. is that data on target as far? does it represent a lot of work left to be done, or is a good sign? and then secondly, how is that data in forming study

specifically for reaching out to that group? mila, you were talking about data is simple to adjust outreach strategy. what is the data telling you this far in terms of what's working and what needs to be done? either going to be specific things to sort of try to bring in those procrastinators that it been talked about? >> just in terms of the data that's coming in, i think this week we saw in states that are going to own marketplaces that are reporting it, significant shares of young adults, about 20% of those who enroll were ages, 19-35, in terms of what cbo is projecting, of the seven many people expected to come into the marketplaces next year, about 2.5 million or so are expected to be with, between the ages of 19-35. so about 30% of that total. in our survey data in october,

we did see about 21% of those people who visited the marketplaces and these are people who are uninsured or eligible to come in were 19-29. about 32% were 19-34. we also found a high percentage of young adults, and there was really no difference across the age groups in terms of people who say they're going to come back to the marketplaces or go to the marketplaces like the end of the open enrollment period. and just in terms of the massachusetts experience, young adults have waited somewhat longer but the uninsured rates among young adults is 21% in the year prior to the passage of the law in massachusetts. that rate dropped to 8% in the after. i think it does, the experience, the survey research that we've done, the experience in massachusetts does suggest young adults will come into the market places, the numbers will help do

what we're hoping they would do not only helping them but also stabilizing the market. spent so, we used all sorts of information sources to, on a weekly basis, hit the restart button. i had a meeting with my senior folks every week, looking back at what we know about enrollment, what we know about folks who were on the ground. so if we know that holding an event in the evening results in five people showing up versus launch, you get 50 people to show up, that's where our resources go. so we look at everything that's happened to not only the data we're seeing but also what we're hearing from our sisters. orienteering from brokers in community groups or on the ground. end of the week we slightly shift our strategy. and i can tell you week one at a lot of events planned,

educational events and what i would call show until comic indication people have a fancy term for it. but essential have to use our web portal, the range of prices, products. we found that consumers are coming and ready to enroll. so the following week we make sure we had a assisters and brokers at those events to help people enroll. so we learned a lot about the needs and demands every week, and we we tool to make sure that we are right there and available to help people whatever they are in their decision-making process. >> so are there any specific strategies to reach out to young people? >> it's a big outreach program for things that are yet to be unveiled. so some of our d.c. assist including young invisibles and groups who have worked with university population. and they're doing very creative things. one of our d.c. alpha link

assisters is going to bars to provide information. so they're very creative are and the one thing that we're not doing is kind of door-to-door or going into people's homes. we have essentially said for a number of reasons were not going to allow assisters to do that. but they can be as creative as possible and ask our daily and weekly updates. and we share that among the assisters. what's worked, what hasn't worked as well and how to retool. spent can ask just one last thing? just i think a few minute ago we learned that deadline to sign up for coverage for january 1 is actually been moved back a week to december 23. and i was just wondering if it has an effect on what any of you guys are doing or will have any kind of ripple effect in general.

>> no. we are pushing for december 15 to enroll in fully paid for coverage to be effective january 1. >> we have time for just a couple more questions. and one is directed specifically to you. your mention of the direct enrollment option, that is direct by plans, the questioner wonders whether that raises technology issues firstly? and what potential with this option ever increasing enrollment? >> that's a great question. i don't think hhs ever intended for health care that got to be the single channel for enrollment. and they don't think they ever anticipated they would be the single channel for enrollment in 30 plus states. so there's a provision in the

law that allows carriers and web brokers like e-health and get insured and others to direct enroll consumers directly from their platform into the exchange. and when i said to enroll, enroll in a plan that the carrier is offered or a plan that the web broker is offering. there's been a lot of confusion in the media about this since the president sort of announced direct enrollment has been obscure and has been a lot of information about it. so really how it works and hhs is providing the technology to the federally-facilitated marketplace states and these technologies are called apis, and allow the carriers and the web brokers to plug into the ffm and to direct enroll. there's been some confusion and misrepresentation in the media saying you can't do that because the only way to get a premium subsidy is directly through

healthcare.gov. you can get a premium subsidy through direct enrollment if the technologies allow the. somebody would go to a carriers website or web brokers website, they would take a plan and then you would be securely transferred to the federally-facilitated marketplace, or a state-based exchange, to calculate your premium subsidy. you would then be taken back to the carriers website or the web brokers website to complete your enrollment and the plan that you have chosen. as of today, only carriers that are working directly with the federally-facilitated marketplace or healthcare.gov can do direct enrollment. and while those technologies have finally been completed, they were supposed to go online october 1 but there were a lot of issues just like they were with healthcare.gov on october 1. a lot of the carriers and web brokers are still trying to complete the final integration to make that work. i'm not aware of any state-based

exchanges, and mila, correct me if i'm wrong that are facilitated direct enrollment this year but i know that there are some that intend to do that next year. but to answer the question i think it was the intention of hhs to provide multiple channels to consumers to enroll with state-based exchanges, healthcare.gov and through direct enrollment. it's a little plate in the game to speculate on how well directed moment is going to work considering the technology wasn't completed until just a couple days ago. and again, many of the direct in rowley's are still working on integration issues here. >> any final observations by any of our panelists? sara? >> i just wanted to add one more thing for people have been concerned about consumers in this process of direct enrollment. health plans have to let people know that there are other options available to them on the

marketplace sites, and also about the other range of products, other health plans that the insurer might offer. but clearly this is a way that enrollment might increase over the next few weeks to get towards the end, not that december 23 date. >> that's correct. they need to inform the consumers there are other options on the state exchange and they can opt out of direct enrollment anytime they want to go directly to the state exchange, or the federally-facilitated marketplace if they so desire. >> i just would like to make a plug for tomorrow. we have a citywide enrollment event at mlk library. we're going to have zumba and health screenings and bring your whole family and i encourage all of you to come out. >> okay. well, what an appropriate way to come to the conclusion of this discussion. we may come back to this topic sometime in the near future, in

case there might be a few remaining issues we haven't quite tied up in neat bundles yet. but at this point i think we've learned an awful lot, at least i have, and reminding you as we finish up to hand in the blue evaluation forms after you filled them out if you would. i want to thank our colleagues at the commonwealth funds for their help in planning and, obviously, making a big direct contribution to the success of this briefing. thank you for some of the best, hard and microphone questions that we've had in a long time. and ask you to join me in thanking the panel for a really enlightening session. [applause] ..

[inaudible conversations] >> the washington examiner senior political analyst talks about his book, shaping our nation, and immigration debate.

the former executive director of the commonwealth health insurance connector authority compares the affordable care act health exchanges with those he created in massachusetts in 2006. washington journal is live at 7:00 eastern on c-span. next, a look at the role of the catholic church in world politics and diplomacy. question. what books are you reading on jfk? host: joining us is francis rooney, the author of "the global vatican" and former u.s. ambassador to the holy see from 2005 to 2008. your title says ambassador to the holy see. what's the difference? guest: the sovereignty lies with , which is the locus

of the authority of the influence of the church in the world, represented by the pope and the different constituent organizations of the holy see. the vatican was granted to the holy see in 1989. as far as your position as ambassador, why do we have such a position in the first place? guest: one of the main purposes of the book is to explain the historic, diplomatic role of the holy see and what they have been able to accomplish, and show why it is important for the u.s. to have a diplomatic relationship with them. they have a strong alignment with our fundamental founding principles. ir diplomacy is based on human dignity. we have an ally to work together to leverage our principles in

dealing with governments around the world, oppression around the world, disease in africa. when you go and present yourself to the pope, who do you talk to about policy issues and who helps you discuss about policy issues? has a the holy see secretary of state, which is organized like our department of state. who areeople under him experts in different groups of countries, the same way the state department has desk officers raid -- officers. host: as far as your day-to-day dealings with them, talk about some of the policies you are coming forth for representing the united states -- how did that work, as far as working with the vatican and the holy see? host: first and foremost was iraq. i went to meet pope benedict.

i had to bring up the subject of iraq. turned the page and said, mr. ambassador, there's been enough said about iraq. it's time to bring peace and stability to the people there. we worked on other issues, such as combating human trafficking, aligning the holy see's security -- work. it far pope benedict continued to speak out strongly against the harsh comments in 2005 and 2006, spoke as anainst using religion excuse for violence, coming to terms with radical islam. host: our guest is former

ambassador to the holy see, residing in the vicinity of the vatican. your questions for francis rooney about the position and what he does and the u.s. callests at the vatican -- using the numbers on your screen. you can tweak your questions or comments, or e-mail us. your questions or comments, or e-mail us. how did you end up with a position? guest: george bush appointed me. it is usually around 35% of the president's ambassadorial appointments are people like me. a post like the holy see, which is dependent on the priorities

of the president, lends itself to an employee. host: are there other countries with ambassadors to the holy see ? guest: it is one of the broadest diplomatic representations in the world. diplomats have been sent to the holy see since the 1950's. host: what is day-to-day like? guest: the role of the u.s. ambassador to the holy see is similar to any ambassador to a secular bilateral mission. communicating about american policy interest in trying to work with them to advance those interests in the normal diplomatic intercourse, if you will.

speaking in the host country about what america stands for, which for me was a great opportunity to speak about the first amendment, our unique first amendment, and our unique melting pot. you just had a gentleman on about immigration. the concept of sovereignty in is based on lineage. our concept of citizenship is based on what you do for america. host: how many times did you meet the pope at that time? guest: twice a year. host: what were those meetings like? how long do they last? guest: the beginning long meeting was about 40 minutes, and i had another meeting with him about 15, 20 minutes wait her. -- 20 minutes. there is next change of pleasantries, five-minute or

three-minute discussion about whatever topical issue is forefront between that country and the holy see at the time. you have talked about america's interests. what were responses when you brought up these issues, whether it be iraq or other issues? this inhere's a lot of the book. the relationship with president bush was strong because of the alignment of his personal and political philosophies, and the fundamental principles of the holy see. i had a great climate for conducting diplomacy. my predecessors and successors had it more difficult because of different priorities. the the president of nuclear arrangement in 2006 with india, we had a constructive discussion. forholy see calls elimination of nuclear weapons and for disarmament. we focused the dialogue more on nonproliferation.

we worked on many situations in latin america where we could link together to speak up against the more authoritarian governments we have seen rise up in the last 10 or 12 years. host: the book is "the global vatican." bob is up first on our independent line. wondering overen the last couple of weeks since a hurricane or typhoon hit the philippines, and knowing that the philippines is a catholic country, they basically were set up as a catholic country just like the united states was back in the 15th century. helped set vatican up the united states. vaticanothing about the opening up their bank and helping out down there. i'm sure they're going to rebuild the church is down there, because they have to fill them back up so they can get more money back in their. what does the vatican say about

all these bad priests that are going around doing what they're doing? in the philippines, i'm sure we will see the constituent catholic relief agencies involved. they were there in haiti when there were the horrible earthquakes, as well is a and unitedrders states. he did not elaborate, but he talked about bad priests. the u.s.e scandal and and some parts of western europe may have impacted the influence of the holy see diplomatically, but not a whole lot. many of the areas where religious freedom and human dignity are most at risk politically are areas far removed from the abuse scandals in the u.s. the fundamental principles of the holy see diplomacy is on an entirely different